From the Guidelines
The initial management for palpitations should focus on identifying and addressing potential triggers, assessing for serious underlying conditions, and considering empirical treatment with beta-blocking agents if significant bradycardia has been excluded. When managing palpitations, it is essential to obtain a detailed history, including onset, duration, associated symptoms, and aggravating factors, as well as checking vital signs and performing a 12-lead ECG to detect arrhythmias 1. Some key points to consider in the management of palpitations include:
- Identifying and eliminating precipitating factors such as excessive caffeine, alcohol, nicotine intake, recreational drugs, or hyperthyroidism
- Teaching patients to perform vagal maneuvers
- Considering empirical treatment with beta-blocking agents, provided that significant bradycardia (less than 50 bpm) has been excluded, as recommended by the acc/aha/esc guidelines for the management of patients with supraventricular arrhythmias 1
- Avoiding antiarrhythmic treatment with class I or class III drugs without a documented arrhythmia due to the risk of proarrhythmia
- Referring patients for further diagnostic tests or invasive electrophysiological study and/or catheter ablation if symptoms and clinical history indicate a paroxysmal arrhythmia.
From the Research
Initial Management for Palpitations
The initial management for palpitations involves a step-wise guide to evaluation and management, with the primary goal of identifying patients at highest risk for serious arrhythmias 2.
Evaluation and Diagnosis
- A thorough evaluation is necessary to determine the cause of palpitations, which can be benign or a manifestation of potentially life-threatening conditions 2.
- The use of long-term continuous Holter ECG recording can help detect atrial fibrillation (AF) in patients with high cardiovascular risk and clinical palpitations 3.
- A 14-day continuous ECG-Holter monitoring can detect AF in 14% of patients, with 23.4% of cases detected in the first 24 hours of monitoring 3.
Treatment Options
- Antiarrhythmic drugs, such as flecainide and propafenone, can be used for rhythm control in patients with AF 4, 5.
- However, these drugs can have proarrhythmic effects, particularly in patients with ventricular tachycardia 6.
- A combination of flecainide and metoprolol can reduce AF clinical recurrences and improve tolerability at 1-year follow-up in persistent symptomatic AF 5.
- Anticoagulation therapy and antiarrhythmic drugs are commonly prescribed for patients with diagnosed AF, with 90% of patients receiving these treatments 3.
Patient Selection and Therapy Surveillance
- Appropriate patient selection and therapy surveillance are essential when using Class Ic antiarrhythmics, such as flecainide and propafenone, due to the risk of adverse events and proarrhythmic effects 4.
- Regular ECG monitoring and follow-up are recommended to detect potential complications, such as ventricular arrhythmias, salvos, and non-sustained ventricular tachycardia 6.